annual infection prevention & control …annual infection prevention & control programme ......

ANNUAL INFECTION PREVENTION & CONTROL PROGRAMME

2020 / 2021

This programme may be altered if significant new risks are identified, or resources do not allow the activity to be undertaken. Approval

NHS Greater Glasgow & Clyde Board Infection Prevention and Control Committee

Submitted to:

NHS Greater Glasgow & Clyde Acute Infection Prevention and Control Committee

NHS Greater Glasgow & Clyde Partnerships Infection Prevention and Control Support Group

INTRODUCTION

Welcome to the 2020/2021 NHS Greater Glasgow and Clyde Infection Prevention and Control

Programme. This Programme has been developed on behalf NHS Greater Glasgow and Clyde by

the Board Infection Prevention and Control Committee.

The Infection Prevention and Control Programme exists to co-ordinate and monitor the work of

the Infection Prevention and Control Committees and Teams in preventing and controlling

infection through effective communication, education, audit, surveillance, risk assessment,

quality improvement and development of policies and procedures. The Programme addresses

the national and local priorities for infection prevention and control and extends throughout

healthcare, health protection and health promotion. Operational delivery of the programme is

regularly monitored and reviewed and reported through the detailed work plan.

Infection prevention and control clearly does not rest solely within the domains of our Infection

Prevention and Control Committees and Teams. Everyone has infection prevention and control

responsibilities. Service users who depend on NHS Greater Glasgow and Clyde require all of us

to follow best practice as described in the NHS Greater Glasgow and Clyde Infection Prevention

and Control Manual www.nhsggc.org.uk/infectionpreventionandcontrol and the National

Infection Prevention and Control Manual http://www.nipcm.hps.scot.nhs.uk/.

The Infection Prevention and Control Committees and teams will co-ordinate delivery of this

extensive body of work. All those involved in delivery of healthcare are encouraged to

participate in this programme through your own infection prevention and control actions

whether delivering or receiving healthcare.

NHS GREATER GLASGOW AND CLYDE For more information on Infection Prevention and Control click on the icon on your PC or use link www.nhsggc.org.uk/infectioncontrol

http://www.nhsggc.org.uk/infectionpreventionandcontrolhttp://www.nipcm.hps.scot.nhs.uk/http://www.nhsggc.org.uk/infectioncontrol

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CONTENTS Page

1. KEY PRIORITY AREAS NHS GREATER GLASGOW AND CLYDE ……………………….…….... 3

2. NATIONAL PROGRAMMES/MANDATORY REQUIREMENTS ………………………………… 4

3. ADDITIONAL RECOMMENDED ELEMENTS ………………..………………………………………… 5

4. SECTION 1 - ACTIONS REQUIRED TO MEET KEY PRIORITY AREAS ……………….…….. 6

SECTION 2 - ACTIONS REQUIRED TO MEET NATIONAL AND MANDATORY REQUIREMENTS ………………………………………………………………………..... 8

SECTION 3 - ADDITIONAL RECOMMENDED ELEMENTS …..……………………..……….… 12

5. GLOSSARY ……………………………………….………………………………………………………………. 13

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1. KEY PRIORITY AREAS NHS GREATER GLASGOW AND CLYDE 2020/2021

Requirement Action to be taken by Contribution to the Quality Strategy Outcomes

Support the work of the SG IPC Sub Group

Provide information and evidence as requested to provide assurance to the group.

NHSGGC Board Healthcare is safe for every person every time.

Support the work of the QEUH Independent Review NHSGGC Board Healthcare is safe for every person every time.

Support the work of the Public Enquiry NHSGGC Board Healthcare is safe for every person every time.

Provide IPCT advice on the management of cases of COVID 19 NHSGGC Board The best use is made of available resources.

Healthcare Improvement Scotland (HIS) HAI Standards 2015 - Implement systems and processes to meet the above standards and ensure that all sites in NHSGGC are demonstrating compliance with the standards. Implement the 2020 standards when issued to NHS Scotland.

NHSGGC Board

Healthcare is safe for every person every time. Everyone has a positive experience of healthcare.

Healthcare Associated Infection (HCAI) standards and antibiotic use indicators for Scotland- To reduce MRSA / MSSA bacteraemia by 10% by 2022.


Healthcare Associated Infection (HCAI) standards and antibiotic use indicators for Scotland- To reduce Clostridioides difficile* infection by 10% by 2022. This data is now presented as Healthcare Associated and Community cases.


Healthcare Associated Infection (HCAI) standards and antibiotic use indicators for Scotland. Antibiotic use indicators 1. A 10% reduction of antibiotic use in Primary Care (excluding dental) by 2022, using 2015/16 data as the baseline (items/1000/day). 2. Use of intravenous antibiotics in secondary care defined as DDD / 1000 population / day will be no higher in 2022 than it was in 2018. 3. Use of WHO Access antibiotics (NHSE list) ≥60% of total antibiotic use in Acute hospitals by 2022.


The best use is made of available resources.

Healthcare Associated Infection (HCAI) standards and antibiotic use indicators for Scotland - To reduce E.coli bacteraemia by 25% by 2021/22.


Implement Infection Prevention and Control (IPC) Elements contained within the Excellence in Care Framework.

Associate Nurse Director Infection Prevention and Control (ANDIPC)

Healthcare is safe for every person every time. Everyone has a positive experience of healthcare.

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2. NATIONAL PROGRAMMES / MANDATORY REQUIREMENTS


Topic –Healthcare Associated Infection Reporting Template (HAIRT) Prepare bi-monthly reports on IPC activity within NHSGGC

Director of Infection Prevention and Control/ IPCM

Healthcare is safe for every person every time.

Topic - Surveillance As per HDL (2006)38, CEL11 (2009) and DL (2015)19

IPCT Healthcare is safe for every person every time. Everyone has a positive experience of healthcare.

Topic – Education Implement HIS HAI Standards 2015 (Standard 2). Promote the NHSGGC Standard Infection Control Precautions (SICP) module and NHS Education for Scotland (NES) Scottish Infection Prevention and Control Education Pathway (SIPCEP) pathways within all disciplines.

IPC Education Sub-Group/ NHSGGC Learning & Education

Staff feel supported and engaged.

Topic – IPC Policy Ensure staff have access to the National IPC Manual. Implement HIS HAI Standards 2015 (Standard 6). To produce service-wide Standard Operating Procedures (SOPs) and guidance which are service specific and evidence based. Provide assurance to the NHS Board by monitoring compliance with policies via the IPC Audit Tools (IPCAT).

IPCT Healthcare is safe for every person every time. Staff feel supported and engaged.

Topic – Decontamination Comply with national directives/standards on decontamination of communal patient care equipment and re-usable devices. Implement HIS HAI Standards 2015 (Standard 8).

NHSGGC Head of Decontamination / Decontamination Sub-Group / Creutzfeldt-Jakob Disease (CJD) Sub-Group

Healthcare is safe for every person every time.

Topic –Assurance and Reporting – There is a clear accountability framework which describes reporting from point of care to NHS Board in relation to HAI risks and events.

Director of Infection Prevention and Control/

IPCM

Healthcare is safe for every person every time. The best use is made of available resources.

Topic – Antimicrobial – Support the work of the Antimicrobial Management Team (AMT) in implementing the recommendations contained in ScotMARAP 2014 -2018 DL (2015) 19 and Healthcare Associated Infection (HCAI) standards and antibiotic use indicators for Scotland.

NHSGGC Antimicrobial Utilisation Committee (AUC)

Healthcare is safe for every person every time. Staff feel supported and engaged.

Topic – MRSA / Carbapenamase-producing enterobacteriaceae (CPE) Key Performance Indicators (KPIs) - Support clinical staff to complete MRSA/CPE Clinical Risk Assessment as per CNO (2013) 1. DL (2015) 19 *

*refers only to MRSA screening

NHSGGC Board Healthcare is safe for every person every time. Staff feel supported and engaged.

The best use is made of available resources. Everyone has a positive experience of healthcare.

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3. ADDITIONAL RECOMMENDED ELEMENTS


Topic –Person Centred Care - NHSGGC must secure public involvement in issues related to HAI and have systems and processes in place which provide patients and the public with information on HAI issues.

NHSGGC Board

Everyone has a positive experience of healthcare.

Staff feel supported and engaged.

Topic – Research - NHSGGC will collaborate with the Scottish Infection Research Network (SIRN), Universities and other relevant organisations to take forward research initiatives.

All The best use is made of available resources.

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4. SECTION 1 ACTIONS REQUIRED TO MEET KEY PRIORITY AREAS

Objective: To reduce MRSA/ MSSA Bacteraemia

Objective to be achieved by the following actions Action by Timescale

Continue the enhanced surveillance of MRSA / MSSA bacteraemia.

IPCT Ongoing

Produce a report on the incidence and possible causes of MRSA / MSSA bacteraemia for distribution to the Acute Infection Control Committee (AICC) and the Sector Clinical Governance Groups.

IPCT / Lead Nurse Surveillance

Bi-monthly

Patients with Staphylococcus aureus bacteraemias (SABs) will be monitored to day-30 and if the patient dies and SAB is listed as an underlying or contributory factor on the patient’s death certificate the IPCT will generate a Datix referral. A Datix referral will also be generated if the SAB is considered to be an avoidable harm.

IPCTs / Sector Teams Ongoing

Carry out Peripheral Vascular Catheter (PVC) and Central Vascular Catheter (CVC) audit in areas where a SAB is considered to be device related. This information will be reported to the Lead and Chief Nurses for that area and will be included in the Sector / Directorate SAB report.

IPCT / IPC Data Team Monthly

As part of IPCAT, monitor compliance with PVC, CVC and Urethral Urinary Catheter (UUC) bundles. This will be supported by an additional process to support staff to implement a quality improvement methodology for areas of the audit where the score is not of an acceptable standard.

IPCTs Ongoing

Sector reports will include details on SABs which have resulted in a Datix referral.

IPCT / IPC Data Team Ongoing

Support the NHSGGC SAB Group with clinical representation from all sectors.

Ensure the action plan from this group is sent to the AICC at least twice per year to provide assurance that action has been taken.

Chief of Medicine (CoM), Chief of Nursing/Midwifery (CoN/M), IPCT, Antimicrobial Management Team (AMT) and Education Leads

Ongoing

Meets quarterly

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Objective: To meet HIS HAI Standards (2015)


Continue to provide IPC support to the organisation to facilitate Healthcare Environment Inspectorate (HEI) compliance monitoring against the Healthcare Improvement Scotland HAI Standards (2015).

Nurse Consultant IPC (NCIPC) Ongoing

Support the work of the corporate inspections post publication of any HEI HAI reports.

ANDIPC Commenced 2020

Objective: To reduce Clostridioides difficile Infection (CDI)


Continue production and feedback of Clostridioides difficile Statistical Process Control Charts (SPCs) or interval charts.

IPCT Monthly Dashboard

Monitor compliance with Clostridioides difficile Infection (CDI) policy via the Transmission Based Precautions (TBP) section of IPCAT and the Facilities Management (FM) peer and public review audit.

IPCT At least yearly in all wards / departments

Objective: To reduce E.coli bacteraemia


Add surveillance information to SAB reporting document and target areas of higher than expected incidences for quality improvement process.

IC Data Team Commence 20/21

Analyse data to identify any risk factors which may be amenable to a local intervention.

IPCT Commence 20/21

Objective: To implement IPC elements of excellence in care framework


Lead on HAI initiatives as part of the National Excellence in Care Nursing agenda.

Support link nurses / midwifes to implement IPC initiatives in Excellence in Care (EiC).

ANDIPC Ongoing

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4. SECTION 2

ACTIONS REQUIRED TO MEET NATIONAL AND MANDATORY REQUIREMENTS

SURVEILLANCE AND QUALITY IMPROVEMENT PROGRAMMES

Objective: To undertake surveillance and quality improvement programmes which are compliant with national requirements and which are designed to achieve reductions in HAI. Develop new systems/processes in order to offer a more comprehensive targeted surveillance system for clinicians in NHSGGC.


NHSGGC will comply with HDL (2006) 38, CEL 11 (2009) and DL (2015) 19.

Lead Nurse Surveillance / Surveillance Nurses / IPCTs

Ongoing

IPCT will carry out alert organism / condition surveillance as per the National IPC Manual. IPCT Ongoing

MRSA and C. difficile SPCs or where appropriate interval charts will be issued monthly to all in-patient areas within NHSGGC (acute).

IPC Data Team Monthly

Gram negative organisms in high risk areas will be monitored using SPC charts for Blood Cultures and or Blind Bronchial Alveolar Lavages.

IPC Data Team

Prepare a report on Infection Prevention Control activities and exceptions for each sector within NHSGGC.

IPCT and IPCT Data Team Monthly

Prepare Surgical Site Infection (SSI) reports for the acute service based on mandatory SSI surveillance but also specific SSI surveillance if requested by service users.

Lead Nurse Surveillance / Surveillance Nurses / IPCTs

Monthly and as required

Prepare yearly annual report on SSI in NHS GGC Lead Nurse Surveillance Yearly

EDUCATION

Objective: To ensure that NHSGGC provides an educational framework for all HCWs


Ensure that NHSGGC is compliant with the elements outlined in the HIS HAI Standard 2 and the NHSGGC HAI Education Strategy (Includes education specific recommendations from the Vale of Leven Hospital Inquiry Report).

AMT / Learning & Education / IPCT

Ongoing

Online educational programmes will continue to be updated and will reflect the general as well as the specific educational needs of the workforce.

NHSGGC IPC Education Sub-Group / Education Lead

Ongoing

Report number of education modules undertaken by staff group in sector reports and the IPC report to the Acute Infection Control Committee (also submitted to the Acute Clinical Governance Committee).

IPCT / IPC Data Team Bi-monthly

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EDUCATION

Objective: To ensure that NHSGGC provides an educational framework for all HCWs


The IPCT will continue to support a single Infection Prevention and Control Induction Programme for staff throughout NHSGGC.

NHSGGC IPC Education Sub-Group / Learning & Education for NHSGGC

Ongoing

Provide ongoing education to support Standard Infection Control Precautions (SICPs) and TBP application when delivering healthcare. Direct staff, (including Care Assurance Standards (CAS) IPC Link Nurses) to appropriate modules in the Scottish Infection Prevention and Control Education Pathway (SIPCEP).

NHSGGC IPC Education Sub-Group / Education Lead

Ongoing

IPC POLICY / STANDARD OPERATING PROCEDURE (SOP)

Objective: To maintain and enhance the NHSGGC Infection Prevention and Control Policy Manual


There will be a planned programme for the review / updating of all Standard Operating Procedures (SOPs), Care Check Lists and Strategies as per HIS HAI Standards (2015), Standard 6.

NHSGGC IPCN SOP Sub-Group Ongoing

Develop new SOPs, Care Check Lists and Strategies in response to emerging pathogens and new National Guidance. Support the implementation of National Policies and prepare local SOPs or Risk Assessments as required.

NHSGGC IPCN SOP Sub-Group As required

DECONTAMINATION

Objective: To comply with national and EU regulations regarding decontamination


Review assessment documentation in relation to the updated Advisory Committee on Dangerous Pathogens (ACDP) guidance on “transmissible spongiform encephalopathy agents: safe working and the prevention of infection”. http://www.dh.gov.uk/ab/ACDP/TSEguidance/index.htm

NHSGGC CJD Sub-Group Ongoing

Support the work of the NHSGGC IPC Decontamination Sub-Group (sub-group of BICC) to address operational / technical issues and give advice accordingly.

IPC Decontamination Sub-Group Ongoing

http://www.dh.gov.uk/ab/ACDP/TSEguidance/index.htm

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CLINICAL GOVERNANCE

Objective: To comply with the principles outlined in the HIS Clinical Governance and Risk Management Standards 2005


The IPC service will have structures and processes in place to identify, manage and communicate risks throughout the organisation.

Director of Infection Prevention and Control/ IPCM

Ongoing

Use Datix Clinical Risk Management System to report specific HAI incidents and significant clinical incidents.

All NHSGGC Ongoing

Use Datix to trigger clinical review for cases of severe Clostridioides difficile Infection or cases where Clostridioides difficile Infection appears on any part of the patient’s death certificate.

All Ongoing

Use Datix to trigger clinical review for cases of SAB where it appears on any part of the patient’s death certificate.

All Ongoing

Provide monthly reports to the NHSGGC Acute Clinical Governance Committee. IPCM Ongoing

Complete hot debrief on all incidents and outbreaks. These will be submitted to the IPC committees to ensure shared learning throughout the organisation.

IPCT Ongoing

ANTIMICROBIAL PRESCRIBING

Objective: To support the work of the Antimicrobial Management Team in promoting prudent antimicrobial prescribing across NHSGGC and achieving the actions outlined in ScotMARAP 2014 -2018 & DL (2015) 19.


Support the Antimicrobial Management Team in promoting antimicrobial policies which limit broad-spectrum antibiotics agents implicated in Clostridioides difficile (CEL 11(2009)), MRSA and other similar infections.

AMT / NHSGGC Ongoing

Use infection prevention and control data in relation to Clostridioides difficile and MRSA to quantify the effect of the implementation of the NHSGGC Infection Management Guideline and the Clostridioides difficile Associated Disease (CDAD) Management Guidance.

AMT / IPCT Ongoing

Continue to support the application of guidance/ policies in NHSGGC to meet the requirements of ScotMARAP 2014 -2018 & Healthcare Associated Infection (HCAI) standards and antibiotic use indicators for Scotland.

AMT Ongoing

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MRSA/Carbapenamase-producing enterobacteriaceae (CPE) KEY PERFORMANCE INDICATORS (KPI)

Objective: To ensure that NHSGGC is compliant with CNO (2013)1 & DL (2015) 19


Support clinical staff to complete the MRSA and CPE Clinical Risk Assessment.

NHSGGC / IPCT / IPC Data Team Ongoing

Monitor compliance with the MRSA and CPE Clinical Risk Assessment and return compliance monitoring figures to HPS as per CNO (2013)1. Include compliance figures in directorate report and in HAIRT.

NHSGGC / IPCT / IPC Data Team Ongoing

Objective: Adopt a ‘zero tolerance’ approach to non-compliance with Hand Hygiene


To continue to support staff to undertake local hand hygiene audit compliance.

NHSGGC Local Health Board Co-ordinator (LHBC)

Ongoing

Continue to recruit members of the public to participate in hand hygiene audits.

NHSGGC LHBC Ongoing

Select wards reporting 100% compliance and initiate QA audit.

NHSGGC LHBC Ongoing

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4. SECTION 3

ADDITIONAL RECOMMENDED ELEMENTS

PERSON-CENTRED CARE

Objective: To ensure that systems and processes are in place to secure public involvement in issues related to HAI and that these systems are linked to the NHSGGC Patient Experience framework


Participate in NHSGGC outreach events that aim to involve the public in influencing services provided.

IPCT Ongoing

Members from the Infection Prevention and Control Team will continue to participate in the Monitoring Framework for Cleaning Services Public Partners Involvement (PPI) Review Support Group.

IPCT Ongoing

Public information on HAI issues will be available through a variety of media including public information boards, patient information leaflets and the interface between patients and members of the Infection Prevention and Control Team.

IPCT Ongoing

Public representatives will continue to sit on the Board Infection Control Committee (BICC) and Partnership Infection Control Support Group (PICSG).

IPCT Ongoing

RESEARCH

Objective: To identify research opportunities in NHSGGC and support individuals/ teams to achieve their objectives


The Infection Prevention and Control Team Research Group will support and encourage HAI research.

NHSGGC Ongoing

NHSGGC will collaborate with SIRN, Universities and other relevant organisations to take forward applied and translational research initiatives.

NHSGGC Ongoing

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5. GLOSSARY

ACDP Advisory Committee on Dangerous Pathogens

AICC Acute Infection Control Committee

AMT Antimicrobial Management Team

Alert organism alert condition

Any of a number of organisms or infections that could indicate, or cause, outbreaks of infection in the hospital or community.

Bacteraemia Infection in the blood. Also known as Blood Stream Infection (BSI).

BICC Board Infection Control Committee

CAUTI Catheter-Associated Urinary Tract Infections

CDAD / CDI Clostridioides difficile Associated Disease / Clostridioides difficile Infection (formerly Clostridium difficile )

CEL Chief Executive Letter issued by Scottish Government Health Directorates (SGHD)

CMO Chief Medical Officer

CPE Carbapenamase-producing enterobacteriaceae

CVC Central Vascular Catheter

C. difficile Clostridioides difficile also referred to as C. diff (or C-diff) is a Gram-positive spore-forming anaerobic bacteria. C. difficile is the most common cause of gastrointestinal infection in hospitals.

CRT Clinical Review Tool

FM Facilities Management

HAI Originally used to mean hospital acquired infection, the official Scottish Government term is now Healthcare Associated Infection. HAI are considered to be infections that were not incubating prior to contact with a healthcare facility or undergoing a healthcare intervention. It must be noted that HAI is not always an avoidable infection.

HAIRT Healthcare Associated Infection Reporting Template HEI Healthcare Environment Inspectorate

HCW Healthcare Worker

HDL Health Department Letter

HIS Healthcare Improvement Scotland

HPS Health Protection Scotland

HSE Health & Safety Executive

IPCAT Infection Prevention Control Audit Tool

IPCN/T/O/D/M Infection Prevention and Control Nurse / Team / Officer / Doctor / Manager

LHBC Local Health Board Co-ordinator (Hand Hygiene)

MRSA / MRSA KPIs

Meticillin resistant Staphylococcus aureus. A Staphylococcus aureus resistant to first line antibiotics; most commonly known as a hospital acquired organism. MRSA Key Performance Indicators.

MSSA Meticillin sensitive Staphylococcus aureus

PHPU Public Health Protection Unit

PICSG Partnerships Infection Control Support Group

PVC Peripheral Vascular Catheter

SAB Staphylococcus aureus bacteraemia

ScotMARAP Scottish Management of Antimicrobial Resistance Action Plan

SHFN Scottish Health Facilities Note. Building notes specifically related to IPC in the built environment.

SICPs Standard Infection Control Precautions

SIPCEP Scottish Infection Prevention and Control Education Pathway

SIRN Scottish Infection Research Network

SOP Standard Operating Procedure

SPC Statistical Process Control Charts

SPSP / SPSI Scottish Patient Safety Programme / Scottish Patient Safety Indicators

TBPs Transmission Based Precautions

UUC Urethral Urinary Catheter

The NHS Greater Glasgow & Clyde Infection Prevention and Control Programme recognise that a wide variety of healthcare is undertaken in diverse settings and this may lead to additional initiatives being undertaken locally.

annual infection prevention & control …annual infection prevention & control programme ......

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